What type of specialist should a patient with bursitis see, an orthopedic (ortho) specialist or a rheumatologist (rheum)?

Bursitis Specialist Referral

For most cases of bursitis, initial management should be handled by primary care, with referral to orthopedic surgery for surgical candidates or refractory cases, and referral to rheumatology only when systemic inflammatory disease (rheumatoid arthritis, gout, lupus) is suspected as the underlying cause.

Clinical Decision Algorithm

Step 1: Rule Out Systemic Inflammatory Disease

• Refer to rheumatology if the patient presents with polyarticular involvement, morning stiffness >1 hour, elevated inflammatory markers (ESR, CRP), positive rheumatoid factor or anti-CCP antibodies, or other signs of systemic rheumatic disease 1, 2
• Refer to rheumatology urgently (within 2-4 weeks) for suspected inflammatory polyarthritis with symmetric joint involvement to prevent irreversible joint damage 1
• Chronic inflammatory bursitis secondary to gout or rheumatoid arthritis requires treatment of the underlying condition by rheumatology, often with intrabursal corticosteroid injections 3

Step 2: Determine if Surgical Intervention is Needed

• Refer to orthopedic surgery for bursitis refractory to 4-6 weeks of conservative management, including rest, ice, NSAIDs, and activity modification 2, 4
• Surgical candidates include those with recalcitrant trochanteric bursitis, retrocalcaneal bursitis requiring resection of prominent posterior calcaneus, or recurrent septic bursitis not responsive to antibiotics 5, 4
• For Haglund's deformity with associated bursitis, refer to podiatric foot and ankle surgeon if no improvement occurs within 6-8 weeks of conservative treatment 5

Step 3: Primary Care Management for Isolated Bursitis

• Most cases of superficial bursitis (prepatellar, olecranon, retrocalcaneal) respond to conservative management and do not require specialist referral 3, 4
• Chronic microtraumatic bursitis should be treated conservatively by addressing underlying causes (repetitive motion, obesity, metabolic conditions) without routine aspiration to avoid iatrogenic septic bursitis 2, 3
• Acute traumatic/hemorrhagic bursitis is managed with ice, elevation, rest, and analgesics; aspiration may shorten symptom duration 3

Location-Specific Referral Considerations

Prepatellar and Olecranon Bursitis

• Primary care can manage with corticosteroid injection after 4-6 weeks of failed conservative therapy 2
• Refer to orthopedics if open excisional procedures or arthroscopic bursectomy is needed for unresponsive cases 6

Trochanteric Bursitis

• Ultrasound-guided bursal injection with lidocaine or corticosteroid can be performed in primary care 2
• Refer to orthopedics for surgical intervention if refractory to conservative management 4

Retrocalcaneal Bursitis

• Never inject corticosteroids into the retrocalcaneal bursa due to risk of Achilles tendon damage 2, 4
• Refer to podiatric foot and ankle surgeon for immobilization casting or surgical resection if no improvement after 6-8 weeks 5

Critical Pitfalls to Avoid

• Always rule out septic bursitis before any treatment, as corticosteroid injection can worsen infection 2, 3
• Never inject corticosteroids into a potentially infected bursa; perform bursal aspiration with Gram stain, crystal analysis, glucose measurement, blood cell count, and culture if infection is suspected 3
• Do not routinely aspirate chronic microtraumatic bursitis to prevent iatrogenic septic bursitis 2, 3
• Missing systemic inflammatory disease (rheumatoid arthritis, lupus, gout) leads to delayed treatment and irreversible joint damage; maintain high index of suspicion for polyarticular involvement 1, 2

When Rheumatology is Essential

The European League Against Rheumatism emphasizes that management of musculoskeletal conditions requires a coordinated, integrated, multidisciplinary approach 5. Rheumatology referral is mandatory when:

• Bursitis is part of a systemic inflammatory or autoimmune process (rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis) 1
• Crystal-induced bursitis (gout, pseudogout) requires long-term management of underlying metabolic disease 2, 3
• Polyarticular symptoms with elevated inflammatory markers suggest inflammatory arthropathy requiring urgent evaluation 1